From Iowa to Asheville and Back: An Accountable Care Perspective from the Trenches

Anthony Pudlo, PharmD, MBA, BCACP

Published Online: Friday, August 22, 2014

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New care team models are springing up across the country.
To address calls to improve the coordination of chronic care, new models for multidisciplinary care teams continue to be evaluated in areas across the country. One approach, accountable care organizations (ACOs), involves bringing doctors, hospitals, and other care providers together to deliver coordinated high-quality care to a panel of patients (eg, Medicare beneficiaries). Given the importance of medication therapy in the management of chronic conditions, pharmacists can be key members of the ACO care team. Given the typical geographic dispersion of an ACO’s patient population, community pharmacists are well-positioned to deliver services, such as medication therapy management (MTM), to address medication nonadherence and other medication issues at the time around hospital discharge and other transitions through the health care system.

This concept of team-based care isn’t new. Pharmacist-based care programs such as The Asheville Project have been referenced as innovative mechanisms to ensure quality patient care at reduced costs. As our profession moves onward with efforts to achieve provider status, the services that pharmacists provide will continue to be evidence for achieving the “triple aim” of improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care.

As a pharmacist who received training in Iowa followed by a residency in North Carolina, I have been fortunate to experience the commitment of our profession to successful implementation and integration of pharmacist services across the continuum of care into various models of care, including an ACO. Most recently, the Iowa Pharmacy Association (IPA), along with key partners at OutcomesMTM and the University of Iowa, with generous support by the McKesson Corporation, Community Pharmacy Foundation, and the National Association of Chain Drug Stores Foundation, have played an integral part in engaging community pharmacy in discussions on innovative practice models across Iowa. Since 2011, IPA has been working extensively with UnityPoint Health, the nation’s 13th-largest nonprofit health system, to integrate pharmacist services within its ACO model. IPA has coordinated meetings with UnityPoint Health executives and ACO implementation teams throughout 2011 and 2012. These meetings provided IPA staff with the opportunity to gauge initial interest in the inclusion of community pharmacists within their Pioneer ACO application. These meetings progressed over time to become opportunities to develop and help shape the model for community pharmacists within their Pioneer ACO centered in Fort Dodge, Iowa.

On December 19, 2011, UnityPoint Health–Fort Dodge was named one of the CMS-awarded Pioneer ACOs, covering an 8-county region in north central Iowa, including Trinity Regional Medical Center and Trimark Physicians Group. IPA’s collaboration with additional pharmacy stakeholders and partners at UnityPoint Health will study the effects of MTM services delivered in tandem by community pharmacists and health-system pharmacists in an integrated MTM program within the Pioneer ACO.

Twenty-eight community pharmacies throughout the rural 8-county region have agreed to participate in this project. The model developed by UnityPoint Health and IPA provides MTM services by utilizing both community pharmacists and ACO clinical pharmacists so that the MTM services will: (1) be coordinated by the ACO’s clinical pharmacists, (2) include a post–hospital discharge medication reconciliation MTM service for targeted patients, and (3) include follow-up MTM services to address ongoing drug therapy problems (eg, nonadherence) for older adult patients living in the community. The ACO believes that this mix of MTM services will reduce hospitalizations, hospital readmissions, emergency department (ED) visits, and per capita costs through a 2-year study period. Specific objectives of this project and evaluation are:

(1) Assess the effects of an integrated MTM program for ACO patients on all-cause hospitalization rates.

(2) Assess the effects of an integrated MTM program for ACO patients on 30-day hospital readmission rates.

(3) Evaluate the impact of an integrated MTM program on the incidence of adverse drug events that result in ED visits for ACO patients.

(4) Assess the effect of an integrated MTM program on per capita Part A and B Medicare costs for ACO patients.

(5) Characterize the types and frequencies of drug-related problems identified and resolved by the pharmacist-delivered MTM services for ACO patients.